Form FDACS-03582 "Lp Gas Category V Installer License Application" - Florida

Form FDACS-03582 is a Florida Department of Agriculture and Consumer Services form also known as the "Lp Gas Category V Installer License Application". The latest edition of the form was released in August 1, 2018 and is available for digital filing.

Download an up-to-date fillable Form FDACS-03582 in PDF-format down below or look it up on the Florida Department of Agriculture and Consumer Services Forms website.

ADVERTISEMENT

Download Form FDACS-03582 "Lp Gas Category V Installer License Application" - Florida

357 times
Rate
(4.7 / 5) 18 votes
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
Make Check or Money Order
payable to FDACS and remit
LP GAS CATEGORY V
with form to:
INSTALLER LICENSE APPLICATION
FDACS
PO Box 6700
ADAM H. PUTNAM
Chapter 527, Florida Statutes
Tallahassee, Florida 32314-6700
COMMISSIONER
Select one:
____ 1 year license ($200)
____ 2 year license ($400)
____ 3 year license ($600)
TO APPLY: Fill this form out completely and return it with all attachments, including the license application fee, to the Bureau
of Compliance [(850)921-1600] at the address in the upper right-hand corner.
Company Name or Corporation:
Business Name or
:
DBA (Name to be printed on license)
Physical Address
:
Company Mailing Address
:
(Address of business to be licensed)
(if different)
City, State, Zip, County
City, State, Zip, County:
Telephone:
Email Address:
(
)
PROOF OF INSURANCE OR BOND MUST BE ENCLOSED WITH YOUR APPLICATION AND FEE.
Pursuant to Section 527.04, F.S., minimum insurance of $1,000,000 bodily injury liability and property damage
liability covering the products and operations of the business is required.
F&A Use Only
Org Code: 42 10 06 25 000
EO: A2
Object Code: 002102
FDACS-03582 08/18
Page 1 of 2
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
Make Check or Money Order
payable to FDACS and remit
LP GAS CATEGORY V
with form to:
INSTALLER LICENSE APPLICATION
FDACS
PO Box 6700
ADAM H. PUTNAM
Chapter 527, Florida Statutes
Tallahassee, Florida 32314-6700
COMMISSIONER
Select one:
____ 1 year license ($200)
____ 2 year license ($400)
____ 3 year license ($600)
TO APPLY: Fill this form out completely and return it with all attachments, including the license application fee, to the Bureau
of Compliance [(850)921-1600] at the address in the upper right-hand corner.
Company Name or Corporation:
Business Name or
:
DBA (Name to be printed on license)
Physical Address
:
Company Mailing Address
:
(Address of business to be licensed)
(if different)
City, State, Zip, County
City, State, Zip, County:
Telephone:
Email Address:
(
)
PROOF OF INSURANCE OR BOND MUST BE ENCLOSED WITH YOUR APPLICATION AND FEE.
Pursuant to Section 527.04, F.S., minimum insurance of $1,000,000 bodily injury liability and property damage
liability covering the products and operations of the business is required.
F&A Use Only
Org Code: 42 10 06 25 000
EO: A2
Object Code: 002102
FDACS-03582 08/18
Page 1 of 2
QUALIFIERS: List the names and certificate numbers of all qualifiers employed by this company below. Attach a separate sheet
if necessary. A separate qualifier is required for every 10 employees.
Indicate number of employees at this location: ____________________
NAME
CERTIFICATE NUMBER
1.
2.
3.
MASTER QUALIFIER: Must function as the owner, manager, or person primarily responsible for overseeing the operations
of the location to be licensed.
I HAVE READ THE ABOVE STATEMENT AND VERIFY THAT I MEET THE ABOVE MASTER QUALIFIER CONDITIONS.
Signature of Master Qualifier:
______________________________________________________
Master Qualifier Name:
Certificate Number:
Date of expiration:
Has the applicant ever been convicted or pled nolo contendere to a felony as defined in Rule 5J-20.005, F.A.C., within
the last five years? If yes, please explain.
NO
YES _____________________________________________________________
Signature of Applicant: _____________________________________________________________
NAME OF PERSON PREPARING APPLICATION:
PREPARER’S PHONE NO:
PREPARER’S EMAIL ADDRESS:
DATE OF APPLICATION:
PREPARER’S TITLE OR OFFICE HELD:
FDACS-03582 08/18
Page 2 of 2
ADVERTISEMENT
Page of 2